Chadsmoor Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Chadsmoor Medical Practice on 11 March 2016. A total of two breaches of legal requirements were found. After the comprehensive inspection, the practice was rated as requires improvement overall.

We issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Safe care and treatment.
• Regulation 17 HSCA (RA) Regulations 2014 Good governance.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chadsmoor Medical Practice on our website at www.cqc.org.uk.

We undertook an announced comprehensive inspection on 27 October 2016 to check that the practice now met legal requirements.

Our key findings were as follows:

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients told us that they were able to get appointments when they needed them, with urgent appointments available the same day.
• The practice had made improvements to the process for recording, investigating and learning from incidents that may affect patient safety. An effective system had been introduced for reporting and recording significant events.
• The practice had introduced a governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
• Processes had been introduced to monitor the performance of the practice. This included significant events and complaints. Performance was discussed at the monthly practice meetings.
• Improvements had been made to the system for handling complaints and concerns. We saw that all complaints, both written and verbal, were recorded, investigated and responded to. Learning from complaints was shared with staff.
• The provider was aware of and complied with the requirements of the duty of candour.
• Risks to patients were assessed although the management in some areas needed to be improved. For example, servicing of the fire alarm and emergency lighting and addressing the recommendations in the legionella risk assessment.

There areas where the provider should make improvements are:

• Review all members of staff’s understanding of the role of a chaperone and where they should stand whilst the examination was taking place, to ensure they are following the practice policy.
• Move the cleaning mops to a more suitable storage area.
• Address the recommendations made in the legionella risk assessment.
• Carry out a fire drill which includes the evacuation of patients.
• Ensure the fire alarm and emergency lighting are serviced in line with the manufacturer’s guidance / current legislation.
• Provide fire marshal training for the designated member of staff.
• Provide information to patients about the availability of the translation service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chadsmoor Medical Practice on 11 March 2016. We revisited the practice on 4 April 2016 to clarify information around record keeping, monitoring of patients with certain medical conditions and emergency medicines. Overall the practice is rated as requires improvement.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, the practice did not have a robust system in place for reporting and recording significant events, and there was no evidence of learning and communication with staff.
• The practice did not have robust arrangements for identifying, recording and managing risks and implementing mitigating actions. For example: the risk to reception staff from handling samples or clinical waste had not been assessed or their immunisation status recorded and a risk assessment had not been carried out to explain the rationale why a DBS check had not been completed for all members of staff.
• Data showed patient outcomes were low compared to the locality and nationally. There was little evidence to support that Quality and Outcomes Framework (QOF) data was monitored and discussed and it was not clear if any member of staff took responsibility for monitoring QOF outcomes.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• Patients told us they could usually get an appointment when they needed one, with urgent appointments available the same day. Patients could also access urgent appointments via the Cannock Network Project.
• The practice had no clear leadership structure and limited formal governance arrangements.

There were particular areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Introduce a robust system for reporting, recording, reviewing and learning from significant events.
• Assess the risk to reception staff from handling samples or clinical waste.
• Implement a system to monitor the use of prescription stationery.
• Implement a system to ensure that the practice nurses and phlebotomists have indemnity insurance in place.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

In addition the provider should:

• Ensure that all the Disclosure and Barring checks for staff relate to their current employment.
• Implement a system to ensure regular meetings are held within the practice and information discussed at meetings is minuted and shared with the appropriate staff members.
• Implement a robust recall system for patients with long term conditions.
• Introduce a system to record verbal/informal complaints.

Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice